COM

1. Chronic otitis media
Dr. AJAY MANICKAM
JUNIOR RESIDENT
DEPARTMENT OF OTOLARYNGOLOGY
RG KAR MEDICAL COLLEGE

2. COM
 CHRONIC INFLAMATION OF THE
MUCO-PERIOSTEAL LINING OF
THE MIDDLE EAR CLEFT
Tubotympanic
/ safe type Atticoantral /
Unsafe type

3. Tubotympanic type
 Safe type
 Inactive / Active / Healed mucosal type
 Predisposing factors
1. Inadequate treatment of AOM
2. Infection of Nose, naso or
oropharynx
3. Tuberculosis
4. Sclerotic mastoids

4. COM aetiology
Streptococcus
Staphylococcus
Gram negative
organisms like
pseudomonas, proteus,
E coli

5. Pathogenesis
 Middle ear mucosa became
edematous and velvety in active
disease Ossicular chain may
undergo necrosis, particularly the
long process of incus
 Hyalinization and subsequent
calcification of sub epithelial
connective tissue leading to

6. Symptoms
Discharge – profuse, mucoid,
nonpurulent, increasing with
attack of cold
Deafness – mild conductive
Earache – otitis externa if
associated

7. Signs
 Discharge in the EAC
 Central Perforation – usually pars
tensa
 Tuning fork test – rhinne negative
weber lateralised to affected side
Central perforation Subtotal
perforation
Total perforation

8. Investigations
 Pus for C/S
 Examination with otoscope /
microscope
 PTA
 X-ray of mastoids [lat obq]
 X-ray of PNS
 X-ray nasopharynx
 Diagnostic nasal endoscopy

9. Management
Medical
1. Aural toilet – dry mopping ,
suction clearance under
microscope
2. Antibiotic ear drops
3. Systemic antibiotics if acute
exacerbation of the disease

10. Surgical
management
 Removal of septic
foci – tonsillectomy ,
adenoidectomy ,
sinus clearance
 Myringoplasty
 Tympanoplasty
 If associated
mastoiditis – cortical
mastoidectomy

11. Atticoantral disease
 CHOLESTEATOMA skin in the wrong
place – sac in the middle ear which is
lined by keratinizing squamous
epithelium containg desquamated
epithelium as keratin debris
Congenital Acquired
1. Primary
2. Secondary

12. Theories of cholesteatoma
 Retraction pocket
theory
 Theory of
migration
 Metaplasia theory
 Implantation
theory

13. Pathogenesis of
cholesteatoma
Tubal
occlusion
BEZOLD
Embryonic cell
remnant
WITTMACK
Epithelial
embryonic
cell Mc
KENZIE
Negative attic pressure
Attic retraction pocket
Squamous epithelium in
middle ear
Normal
pavement
epithelium
TUMARKIN
Epithelial metaplasia
CHOLESTEATOMA

14. Symptoms
 Ear discharge – foul smelling scanty
predominantly purulent occasionally
blood stained
 Deafness
 Itching and pain in the ear – with otitis
externa
 Tinnitus & giddiness – early symptoms
of complication

15. Signs
 Attic, marginal or total perforation
 Granulation tissue or keratin flakes in
the postero superior quadrant of deep
meatus
 Tuning fork test – rinne negative ,
weber lateralized to the affected side

16. Investigations
 Examination under microscope
 C/S from discharge
 Rigid oto endoscopy – to see facial
recess and sinus tympani if possible
 PTA
 X-ray mastoid schuller’s & laws view
 HRCT temporal bone

17. Management
 Primary – make ear safe
 Restore hearing
 Maintain anatomical appearance of
ear
 Medical management – no role or
patients unfit for surgery . 5 flurouracil
has been tried – regular follow up
 Main line of management is
SURGERY

18. SURGERY
 Canal wall down mastoidectomy –
radical or modified radical
 Canal wall up mastoidectomy –
combined approach tympanoplasty